E-cigarette use in low-income and middle-income countries: opportunity or challenge for global tobacco control
Authors: Mohammad Ebrahimi Kalan, Raul Mejia, Catherine O Egbe, Mansi Chopra, Dima Bteddini, Rime Jebai, Olatokunbo Osibogun, Anna V Wilkinson, Ramzi G Salloum
Journal: The Lancet Global Health (2023)

Tobacco smoking kills more than 8 million people worldwide annually, with a disproportionately high burden of these deaths occurring in low-income and middle-income countries (LMICs).1WHOWHO report on the global tobacco epidemic, 2023: protect people from tobacco smoke. World Health Organisation, Geneva2023Google Scholar About 80% of the world's 1·3 billion tobacco users live in LMICs.1WHOWHO report on the global tobacco epidemic, 2023: protect people from tobacco smoke. World Health Organisation, Geneva2023Google Scholar The emergence of electronic nicotine delivery systems (ENDS) could contribute to either reducing or exacerbating this burden, depending on how their accessibility and use is regulated. Although ENDS have gained some popularity in LMICs, their prevalence still lags behind the current usage rates in high-income countries (HICs).1WHOWHO report on the global tobacco epidemic, 2023: protect people from tobacco smoke. World Health Organisation, Geneva2023Google Scholar The adoption of ENDS varies across countries and regions, and this variation is influenced by diverse cultural and policy environments, often swayed by tobacco industry interests.2Kennedy RD Awopegba A De León E Cohen JE Global approaches to regulating electronic cigarettes.Tob Control. 2017; 26: 440-445Crossref PubMed Scopus (170) Google Scholar, 3WHOTobacco: e-cigarettes.https://www.who.int/news-room/questions-and-answers/item/tobacco-e-cigarettesDate: May 25, 2022Date accessed: June 21, 2023Google Scholar Several key factors affect the prevalence of ENDS use, including economic conditions, cultural norms, laws and regulations around tobacco products, and marketing tactics used by tobacco industry.1WHOWHO report on the global tobacco epidemic, 2023: protect people from tobacco smoke. World Health Organisation, Geneva2023Google Scholar, 2Kennedy RD Awopegba A De León E Cohen JE Global approaches to regulating electronic cigarettes.Tob Control. 2017; 26: 440-445Crossref PubMed Scopus (170) Google Scholar, 3WHOTobacco: e-cigarettes.https://www.who.int/news-room/questions-and-answers/item/tobacco-e-cigarettesDate: May 25, 2022Date accessed: June 21, 2023Google Scholar These factors shape how socially or culturally acceptable and accessible ENDS use is within both LMICs and HICs. As the majority of research investigating the long-term effects of ENDS on population health4Vu GT Stjepanović D Sun T et al.Predicting the long-term effects of electronic cigarette use on population health: a systematic review of modelling studies.Tob Control. 2023; (published online June 9.)https://doi.org/10.1136/tc-2022-057748Crossref PubMed Scopus (1) Google Scholar and its potential to help smokers quit5Hartmann-Boyce J McRobbie H Lindson N et al.Electronic cigarettes for smoking cessation.Cochrane Database Syst Rev. 2021; 4CD010216 PubMed Google Scholar has been conducted in HICs, how and when ENDS products will evolve and be treated in LMICs is unclear. For example, a Cochrane review regarding the potential of ENDS to facilitate smoking cessation highlights studies conducted in the USA (24 studies), the UK (9), and Italy (7), with almost all randomised clinical trials occurring in HICs5Hartmann-Boyce J McRobbie H Lindson N et al.Electronic cigarettes for smoking cessation.Cochrane Database Syst Rev. 2021; 4CD010216 PubMed Google Scholar and no predictive modelling studies of ENDS conducted in LMICs (at the time of writing).4Vu GT Stjepanović D Sun T et al.Predicting the long-term effects of electronic cigarette use on population health: a systematic review of modelling studies.Tob Control. 2023; (published online June 9.)https://doi.org/10.1136/tc-2022-057748Crossref PubMed Scopus (1) Google Scholar This research gap calls for more country-specific studies in LMICs to better understand the unique effects of ENDS products across settings and inform appropriate regulations and policies. The gap also underscores inequities in tobacco control research fundings and outputs between LMICs and HICs. Currently, ENDS products are prohibited in 34 countries.1WHOWHO report on the global tobacco epidemic, 2023: protect people from tobacco smoke. World Health Organisation, Geneva2023Google Scholar In other countries, they are subject to various regulations and classifications, such as tobacco products, consumer products, and therapeutic products, or are completely unregulated.1WHOWHO report on the global tobacco epidemic, 2023: protect people from tobacco smoke. World Health Organisation, Geneva2023Google Scholar, 2Kennedy RD Awopegba A De León E Cohen JE Global approaches to regulating electronic cigarettes.Tob Control. 2017; 26: 440-445Crossref PubMed Scopus (170) Google Scholar, 3WHOTobacco: e-cigarettes.https://www.who.int/news-room/questions-and-answers/item/tobacco-e-cigarettesDate: May 25, 2022Date accessed: June 21, 2023Google Scholar Many countries—mostly LMICs—regulate ENDS with tobacco product legislation not originally intended for ENDS products.2Kennedy RD Awopegba A De León E Cohen JE Global approaches to regulating electronic cigarettes.Tob Control. 2017; 26: 440-445Crossref PubMed Scopus (170) Google Scholar This approach could complicate (and hinder) the effective implementation of regulations against all tobacco products.4Vu GT Stjepanović D Sun T et al.Predicting the long-term effects of electronic cigarette use on population health: a systematic review of modelling studies.Tob Control. 2023; (published online June 9.)https://doi.org/10.1136/tc-2022-057748Crossref PubMed Scopus (1) Google Scholar Therefore, enhancing efforts to discourage tobacco use in LMICs is crucial to expand evidence-based cessation tools and programmes with different approaches. For example, in Lebanon (a country with an exceptionally high tobacco use burden), a new project is connecting patients to phone-based counselling in a health-care system with nicotine replacement therapy being recommended as the most effective alternative to tobacco smoking.6Salloum RG Romani M Bteddini DS et al.An effectiveness-implementation hybrid trial of phone-based tobacco cessation interventions in the Lebanese primary healthcare system: protocol for project PHOENICS.Implement Sci Commun. 2023; 4: 72Crossref PubMed Scopus (1) Google Scholar Although cigarette smoking constitutes the most popular form of tobacco used in HICs, nicotine and tobacco consumption modes widely vary across LMICs. For example, alongside cigarettes, highly prevalent forms of nicotine and tobacco use include waterpipe tobacco smoking in north Africa and the eastern Mediterranean, smokeless tobacco in south Asia, and cigars in South America. These variations can complicate the regulation of emerging products such as ENDS, can hinder opportunities to ease the burden caused by combustible tobacco products in LMICs, and could pose a challenge for tobacco control efforts in these nations.3WHOTobacco: e-cigarettes.https://www.who.int/news-room/questions-and-answers/item/tobacco-e-cigarettesDate: May 25, 2022Date accessed: June 21, 2023Google Scholar, 7Xi B Liang Y Liu Y et al.Tobacco use and second-hand smoke exposure in young adolescents aged 12–15 years: data from 68 low-income and middle-income countries.Lancet Glob Health. 2016; 4: e795-e805Summary Full Text Full Text PDF PubMed Scopus (134) Google Scholar Diverse tobacco product use in LMICs highlight the need for a comprehensive ENDS regulatory approach. One solution is updating the WHO Framework Convention on Tobacco Control (FCTC) treaty to include ENDS rules.1WHOWHO report on the global tobacco epidemic, 2023: protect people from tobacco smoke. World Health Organisation, Geneva2023Google Scholar Although FCTC pre-dates ENDS, WHO has offered separate guidelines.3WHOTobacco: e-cigarettes.https://www.who.int/news-room/questions-and-answers/item/tobacco-e-cigarettesDate: May 25, 2022Date accessed: June 21, 2023Google Scholar Merging ENDS into FCTC articles would unite global tobacco control, aiding countries, especially LMICs, in context-specific regulations. The use of ENDS is now widespread in HICs, despite regulatory restrictions in some jurisdictions.1WHOWHO report on the global tobacco epidemic, 2023: protect people from tobacco smoke. World Health Organisation, Geneva2023Google Scholar, 3WHOTobacco: e-cigarettes.https://www.who.int/news-room/questions-and-answers/item/tobacco-e-cigarettesDate: May 25, 2022Date accessed: June 21, 2023Google Scholar The complexities of these products present a regulatory challenge globally. Lessons learned from regulatory actions, mostly in HICs, emphasise the importance of comprehensive ENDS regulations that address all aspects, including advertising promotion and sponsorship, and taxation. Additionally, restricting or banning the sale of ENDS products with enticing flavors that appeal to young people can have a crucial role in preventing youth use.8Ollila H Tarasenko Y Ciobanu A Lebedeva E Raitasalo K Exclusive and dual use of electronic cigarettes among European youth in 32 countries with different regulatory landscapes.Tob Control. 2023; (published online April 25.)https://doi.org/10.1136/tc-2022-057749Crossref Scopus (2) Google Scholar However, in LMICs, evidence regarding the magnitude of ENDS use and its efficacy and safety remains sparse. Moreover, ENDS products have penetrated consumer markets in most LMICs rapidly, often overtaking the development of clinical practice guidelines or regulatory frameworks.9Novotny TE van Schalkwyk MCI How should physicians in low- and middle-income countries regard electronic nicotine delivery systems to facilitate smoking cessation?.AMA J Ethics. 2020; 22: E82-E92Crossref PubMed Scopus (1) Google Scholar According to WHO's 2023 report, 85% of HICs have either a regulation or a sales ban in effect, yet 40% of middle-income and about 80% of low-income countries have taken no regulatory action against ENDS.1WHOWHO report on the global tobacco epidemic, 2023: protect people from tobacco smoke. World Health Organisation, Geneva2023Google Scholar Moving forward, consistent monitoring of population-based ENDS use in LMICs is crucial to establishing and implementing evidence-based ENDS policies. On the basis of WHO's 2023 report,1WHOWHO report on the global tobacco epidemic, 2023: protect people from tobacco smoke. World Health Organisation, Geneva2023Google Scholar of the 59 countries that monitor ENDS use, 38 are HICs, 21 are middle-income countries, and zero are low-income nations. In addition, health-care professionals and the public require further research on the risks of ENDS in local populations to inform evidence-based policies and practices. These efforts require additional investments from global and regional funding agencies, such as WHO and the National Institutes of Health. Maximising efforts and research on the effects of ENDS is crucial to effectively prevent and control tobacco and nicotine products use not only in LMICs, but also on a global scale. OO is supported by the National Institute on Drug Abuse of the National Institutes of Health under award number K01DA055127. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health. All other authors declare no competing interests. Members of the Global Tobacco Research Network at Society for Research on Nicotine and Tobacco are listed in the appendix. Download .pdf (.14 MB) Help with pdf files Supplementary appendix